Tsuang Fon-Yih, Hsu Yu-Lun, Chou Tzu-Yi, Chai Chung Liang
Division of Neurosurgery, Department of Surgery, National Taiwan University Hospital, No.1, Changde St., Zhongzheng Dist., Taipei City, 100229 Taiwan; Spine Tumor Center, National Taiwan University Hospital, No.1, Changde St., Zhongzheng Dist., Taipei City, 100229 Taiwan.
School of Medicine, College of Medicine, National Taiwan University, No. 1, Section 1, Ren'ai Rd, Zhongzheng District, Taipei City, 100229 Taiwan.
Spine J. 2025 Jun;25(6):1096-1107. doi: 10.1016/j.spinee.2024.11.015. Epub 2024 Nov 29.
The debate over adding fusion after decompression in lumbar spinal stenosis patients without spondylolisthesis is due to the "absence of evidence" in its benefits, particularly in reoperation. However, this "absence of evidence" does not indicate "evidence of absence."
To investigate the reoperation rates following the addition of fusion after decompression in patients with lumbar spinal stenosis without spondylolisthesis.
Systematic review and meta-analysis.
We searched Medline, Embase, Web of Science, and Google Scholar databases on December 12, 2021, with an updated search conducted on April 06, 2023. Inclusion criteria were adult patients with lumbar spinal stenosis. Exclusions comprised cases of spondylolisthesis and instabilities. The occurrence of reoperation was summarized using odds ratios (OR), while other outcomes were presented as mean differences. We employed a Cox-based shared-frailty model with random effects for the time-to-event analysis of reoperation. Additionally, we used a 2-stage method to validate our estimates. Heterogeneity variance within the random-effects model was estimated using the Hartung-Knapp-Sidik-Jonkman method.
A total of 1973 studies were identified and screened, of which 48 met selection criteria, and 17 were included in the meta-analysis. Comparison between fusion and nonfusion groups in patients with lumbar stenosis and neurological claudication revealed no significant difference in reoperation rates (odds ratio: 1.13 [95% CI: 0.88 to 1.46]; 8016 participants; 14 studies; I = 0%). Bayesian analysis indicated an 8.9-fold likelihood of similar reoperation rates. Time-to-reoperation analysis revealed a 16.46 months delay in the fusion group, though not statistically significant (mean difference: 16.46 [95% CI: -3.13-36.04]; 83 participants; 3 studies; I = 46%). Consistently, ODI, back pain, and leg pain VAS showed no significant differences. The certainty of the evidence was low for odds of reoperation and leg pain VAS, and very low for the remaining outcomes.
In lumbar spinal stenosis patients without spondylolisthesis, the addition of fusion after decompression showed limited benefits in terms of reoperation rates, ODI, and leg pain.
对于无椎体滑脱的腰椎管狭窄症患者，在减压后是否增加融合手术存在争议，原因是其益处“缺乏证据”，尤其是在再次手术方面。然而，这种“缺乏证据”并不意味着“证据不存在”。
研究无椎体滑脱的腰椎管狭窄症患者在减压后增加融合手术后的再次手术率。
系统评价和荟萃分析。
我们于2021年12月12日检索了Medline、Embase、Web of Science和谷歌学术数据库，并于2023年4月6日进行了更新检索。纳入标准为成年腰椎管狭窄症患者。排除标准包括椎体滑脱和不稳定病例。再次手术的发生率用比值比（OR）进行总结，而其他结果则以均值差异表示。我们采用基于Cox的随机效应共享脆弱模型对再次手术的事件发生时间进行分析。此外，我们使用两阶段方法来验证我们的估计。随机效应模型中的异质性方差使用Hartung-Knapp-Sidik-Jonkman方法进行估计。
共识别和筛选出1973项研究，其中48项符合选择标准，17项纳入荟萃分析。腰椎管狭窄症合并神经源性间歇性跛行患者的融合组与非融合组比较，再次手术率无显著差异（比值比：1.13[95%CI：0.88至1.46]；8016名参与者；14项研究；I²=0%）。贝叶斯分析表明，再次手术率相似的可能性为8.9倍。再次手术时间分析显示，融合组延迟16.46个月，尽管无统计学意义（均值差异：16.46[95%CI：-3.13至36.04]；83名参与者；3项研究；I²=46%）。同样，ODI、背痛和腿痛视觉模拟评分（VAS）无显著差异。再次手术几率和腿痛VAS的证据确定性低，其余结果的证据确定性极低。
对于无椎体滑脱的腰椎管狭窄症患者，减压后增加融合手术在再次手术率、ODI和腿痛方面益处有限。
